Found out today that all magazines and toys have been removed from waiting rooms for clinics at Ryehill health centre on Perth Road. Mother attending the clinic says its a nightmare bringing two kids along because there's nothing for them to do. Managed to ask the midwife at the clinic (Linda) lots of antenatal health questions and she was really helpful. Performed several abdominal palpations and got to play with the hand held Doppler.

Read the following article about H1N1 virus today on the BMJ website:

'Two swine flu call centres in England will close on Sunday with the loss of 1200 jobs reports The Guardian. Demand for Tamiflu has plummeted: it peaked on 27 July with nearly 39,000 authorisations for the use of Tamiflu while on 16 August there were only 3396. According to the HPA there were only 11,000 new cases of swine flu last week and the GP consultation rates have dropped from a peak of 35 consultations per 100,000 of the population to under 5 (similar to the rate in January this year for seasonal flu). 59 people in the UK are reported to have died from the virus so far.

Time for a break?

With everything seemingly back to normal it’s tempting to forget all about swine flu. But we shouldn’t get too comfortable, as the RCGP mentioned in its weekly flu update: this quiet time should be used to prepare for the next wave of flu. But what more can be done? We’ve already had a dress rehearsal this summer and clinicians’ knowledge, skills and organisation regarding swine flu are now fine-tuned. Perhaps the best thing people can do is take a hard earned break to recharge the batteries for the winter ahead."

Wonder whether it will be a problem when the winter comes around and what I'll be able to do to help treat patients with flu like symptoms in hospital.

Came across a patient today with Ehlers-Danlos syndrome at the high risk antenatal clinic, Ninewells Hospital. Its an autosomally dominant inherited disorder caused by a defect in collagen synthesis and comes on 4 major clinical sub-types - type I to IV. This patient had Type III, also known as 'Hypermobility EDS'. It affects between 1 in 10,000 and 1 in 15,000 people. A serious complication of type 4 EHD is coarctation of the aorta and this patient did have a positive family history of coarctation of the aorta. It was recommended that due to this risk in the patient, the second stage of labour should be as short as possible to minimise risk.

Discussing with the doctor afterwards I learnt that the most important thing about aortic dissection in labour is recognising it by picking up key clinical signs such as marked hypotension, severe chest pain and shock. This severe complication had caused a fatality on the ward in the past year.

On a slightly lighter note, at the pathology MDT meeting the medical stereotypes were out in force, consultant gynaecologist 'surgeons are pretty thick anyway' and my favourite from the pathologist when discussing the patient's tumour 'we could just dissect it on autopsy'. Seriously?

Symptoms of early pregnancy include: nausea, vomiting, dry skin, weight gain, mood changes, chest pain, constipation, heartburn, pelvic pressure / joint pain, carpal tunnel syndrome, vaginal discharge and fatigue. Many of these symptoms disappear after approximately 16 weeks gestation although there's no 'magic cut-off'. Meanwhile UTIs are very common in pregnancy and must be treated as they may cause pre-term labour.

I cannot make up my mind on where I stand regarding the release of Abdelbaset Ali al-Megrahi on compassionate grounds. Ethically if the man was soon to die from terminal cancer, I would support his release to be with his family. However, he is guilty of a crime for which he was given a life-sentence and I can understand why many people are particularly upset by his release. I don't know what's true about the economic discussions taking place between Scotland and Libya and the rumours that his release were part of a trade deal although I sincerely hope they are not true. If they do turn out to be true, it would pose serious questions about the members of the Scottish parliament who warranted his release.

From now on I will take something to do in clinics between patients not turning up, tutors being absent, patients not wanting students present etc instead of wasting hours like this afternoon!

Clinical features:

Hydatidiform Mole: vaginal bleeding, large for dates uterus, passage of vesicles, hyperemesis, early onset pre-eclampsia and hyperthyroidism.

Ruptured Ectopic Pregnancy: Shock, peritonism, haemorrhage, cervical excitation, uterus small for dates.

Tubal Miscarriage: Abdominal pain / peritonism, PV bleeding, uterus small for dates, cervix closed, shoulder pain.

Exciting times, delivered my first baby last night on the labour ward at about 3AM on Sunday morning! After a normal labour (patient brought to labour ward 2 weeks post-dates) para 1 + 0 woman I was able to assist in the delivery of the baby and the placenta with two midwives present in the room. The midwives are all fantastic, all of them have been really welcoming over the past week which has really helped. There was some post-partum haemorrhage, probably caused by trauma to the vagina during the delivery. Blood pressure and haemoglobin levels were closely monitored and the patient made a full recovery. Carried out checks on the placenta for completeness, presence of both the amnion and chorion, and also presence of three blood vessels in the umbilicus. Also was present in theatre earlier in the evening for to witness a forceps delivery.

Been very busy on the labour ward this week, an interesting case from last night:
28 y.o. para 0 + 0 woman presentation breech, admitted to the labour ward from DMU for emergency caesarian section, fetal presentation was confirmed by ultrasound scan. On delivery the baby was seen immediately by the on-call paediatrician with some concerns over baby's breathing. Grunting sounds were heard, heart rate greater than 100. Discussed with the on-call consultant the importance of using accuracy when describing fetal position, lie, and presentation. Learnt that whilst it is possible to have a SVD with a breech fetus, recent evidence has shown that caesarian section has a higher chance of positive outcome.

Thistlegorm

Found this video of YouTube of the Thistlegorm and thought it was definitely worth posting.
http://www.youtube.com/watch?v=UzkVLGi8dMc&feature=related

Labour Ward

Its been an exciting few days, really enjoying the week. So far 2 days, 3 caesarians and 3 healthy babies although still no 'normal spontaneous deliveries' of note. Watching the doctor get consent yesterday was interesting, it seemed to involve about 3 different people explaining all of the details of the op, anaesthetic and risks to both mother and baby.
In theatre today I found out why in women with a high BMI the table has to be tilted. Also saw one of the midwives 'attempt' to catheterise the patient on the table but unfortunately get the wrong hole, oops. Managed to help Dad who looked like he was about to pass out at one point and help him through to the prep room to sit down.
Best things about labour ward: tea and toast in abundance, all of the staff being incredibly friendly and seeing alot of things in my first week. Worst part there's so many people and codes that it's becoming a memory game trying to remember everything! Looking forward to night shifts at the weekend and meeting my supervisor tomorrow. Managed ok in the pre-assessment for the block but definitely need to brush up on my gynae pathology.

Night Shift

A first night

On my first night on call as a surgical junior doctor I was called to a patient on the second day after major bowel surgery. He was agitated, tachycardic, and mildly hypotensive, and the nurses assured me that he had passed only 10 ml of urine in the past four hours. I ran from the opposite corner of the hospital to find a clearly sick and possibly septic patient. His ABCs (airway, breathing, circulation) were good (except for his tachycardia), and he was experiencing abdominal pain but was too agitated to tell me more than that. On examination he was guarding around his lower abdomen; it was very tense, but he still had bowel sounds. His fluid balance chart (not fully completed by the nurses) showed only one litre in over the past 24 hours, and only about 500 ml out (all day from his catheter). Culprit found: “He’s hypovolaemic,” I thought. So we gave him a 500 ml bolus of succinylated gelatin solution for intravenous infusion and followed that up with a six hour bag of Hartmann’s solution. Over the next hour his agitation worsened.

I called the surgical senior house officer, who shouted at me for having woken him, promised to come anyway, and asked if we had given the patient a bladder scan. I had to sheepishly say we hadn’t thought of that. By the time he got there we’d done a bladder scan, which showed more than 900 ml. The catheter clearly needed changing because it was completely blocked. We set up the trolley, ready for me to pass a new catheter, disconnected the catheter bag, and deflated the balloon. I was promptly soaked by the 900 ml of urine before I’d even withdrawn the catheter. The patient breathed a sigh of relief and thanked me, and the senior house officer walked in to find me covered in urine.

My tips for anyone approaching their first set of surgical nights are:

* If a patient has poor urine output flush the catheter and bladder scan them before panicking about fluid challenges
* The senior house officer may be asleep, but the trust is paying them to work, so don’t feel guilty about waking them up if you’re unsure about something
* Always have a spare change of clothes or know the code to the theatre changing room so if you get covered in blood, vomit, or urine you can get changed.

Sarah Jones, F1, Nottingham

Looking forward to my first night shift (sort of) on Friday!

Are you a perfectionist?

Posted by Susan Kersley at 6/7/2009 7:28 AM BST on bmj.com

Are most doctors perfectionists? Do you agree? Are you driven by wanting to be perfect or a fear of litigation?
Rather than perfect Is it OK to be 'good enough' rather than perfect?
What is the distinction between being 'good enough' and being 'perfect' ?
It just isn't possible, however careful you are, to be 100% perfect all of the time.

Dr. A might not make a decision without consulting a superior, whereas Dr. B doesn't consider all the possible outcomes of his actions and does something without weighing up the possible outcome.

In Medicine you may not be certain of the way things will turn out. You can only consider probabilities. A surgeon will warn a patient of the all the possible complications of an operation. As a doctor you may not be able to predict precisely what will happen to the patient you can only talk of likelihood and possibility. You have to be clear about the outcome the patient and you want and address these issues. This applies to life in general : you cannot be 100% certain of the outcome of a certain action, you can ony look at what might happen and then make a decision based on: evidence, your gut feelings, what people tell you and what you see happening to others in similar circumstances. So be clear about what you want and 'just do it' - you don't have to be perfect!

http://news.bbc.co.uk/sport1/hi/football/teams/a/arsenal/8201233.stm
Nice one Arsene

Looking back at Scotland's 4 - 0 defeat to Norway tonight, i'm finding it more and more difficult to see the tartan army qualifying for the World Cup Finals in South Africa. I thought that Gary Caldwell's sending off was harsh, and totally changed the game. It should have been 5 - 0 had it not been for some suspicious linesman decisions. At least things are looking better for England, and I really hope Northern Ireland qualify purely so I can watch the games in the finals with the Dundee Uni N. Ireland supporters club!

I now know that the first week of the Obs & Gynae block I'm going to be on the labour ward, including 2 night shifts next weekend! I really think its going to be a case of being thrown in at the weekend and it'll probably be a steep learning curve but I'm looking forward to it. Some tips from Amy are to revise how to write a partogram, different delivery methods and how to scrub in. Maybe I'll look over some things in the next few days before starting but we'll see how that goes! Even just sorting through all the info on Blackboard today it seems like ALOT of info to digest but I think as long as I'm well organised i'll manage the workload.

Meanwhile I just bought the Ricky Gervais podcast with Karl Pilkington which I'm really hoping lives up to the hype!

10th August 2009

I guess my reason for starting the blog is to keep other people (and myself) up to date on what's going on this next year. Hopefully if I can actually get on here regularly enough it'll be a good place to write down my experiences and remember them when it the time comes around.

Right now, I'm just back from Borneo, having been away for 6 weeks on the D.A.R.E. project. Although I'm thinking maybe we should call it the D.A.V.E. or R.A.V.E. society next year! 4th year starts in one week, I tried to do one hour of studying tonight and that lasted all of 10 minutes... Think it's going to be a steep learning curve next week starting on the Obs & Gynae block!